Clinical Documentation Specialist

UCHealth; South Dakota; Remote; USD 106,191,000 - 164,589,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Tuition reimbursement

Performance bonus and merit increases

Job summary

UCHealth is seeking a Clinical Documentation Specialist to perform concurrent review of medical records to ensure compliant, accurate reimbursement based on severity of illness, risk of mortality, and level of services provided. You will collaborate with physicians, nursing, coding, and other staff to ensure documentation is complete and accurate.

This 100% remote role accepts out-of-state candidates. Requires RN/BSN/NP/PA/MD and licensure, with 5 years of acute inpatient experience or CDI

Qualifications

• Graduate of an accredited Registered/Professional Nursing program (RN/BSN) or advanced practice degree (NP/PA/MD).
• US-accredited programs accepted for international graduates.
• Current RN/NP/PA license; MD/DO allowed without active RN/NP/PA licensure.

Responsibilities

• Reviews inpatient records to document diagnoses/procedures and assign DRG.
• Identifies need to clarify documentation; communicates with providers.
• Performs follow-up reviews for physician queries.
• Collaborates with coding staff to ensure accurate reflection of patient status.
• Maintains knowledge of changing requirements and guidelines.
• Demonstrates critical thinking and works with minimal supervision in fast-paced settings.

Skills

Clinical Documentation

DRG assignment

Querying physicians

Collaboration with teams

Education

RN/BSN/NP/PA/MD

State RN/NP/PA license

Job description

Description

Clinical Documentation Specialist

Location: UCHealth Leprino Building AMC, Aurora CO

Department: Clinical Documentation Integrity

Work Schedule: Full Time, 80.00 hours per pay period (2 weeks)

Shift: Days

Pay: $37.06 - $57.44 / hour. Pay is dependent on applicant's relevant experience

This position is 100% remote. Qualified, eligible out-of-state candidates may be considered.

Summary:

Performs concurrent review of clinical documentation in written and electronic medical records to ensure compliant, appropriate and accurate reimbursement based on severity of patient illness, risk of mortality and level of services provided to patients. Collaborates with physicians, nursing staff, ancillary departments, and coding staff to ensure clinical documentation is compliant, complete and accurate. Provides ongoing education and support to the healthcare team in regard to clinical documentation in the medical record.

Responsibilities:

Reviews inpatient medical records for areas of opportunity regarding clinical documentation of diagnosis and procedures to assign a working DRG for identified population. Conducts reviews and documents findings.

Identifies need to clarify documentation in records; communicates with providers to capture documentation that supports the severity of illness and risk of mortality. Conducts follow up reviews for responses to physician queries. Serves as a resource to physicians and staff.

Works with coding staff to assure documentation of diagnoses and comorbidities or complications are a complete reflection of the patient's clinical status and care.

Maintains knowledge of requirements and guidelines to include changes/updates to practice or requirements.

Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action.

Requirements:

• Graduate of an accredited or state board of nursing approved Registered/Professional Nursing program. Associate or Bachelor of Science in Nursing (RN / BSN) or Nurse Practitioner (NP) or Physician Assistant (PA), or a medical degree (MD/DO). US-accredited international medical programs are accepted.

• State licensure as a Registered Nurse (RN) or Nurse Practitioner (NP) and Registered Nurse (RN) or Physician Assistant (PA). No active licensure is required for MD/DO.

• 5 years of recent clinical experience in an acute inpatient setting OR 1-year recent CDI experience. Preferred: Critical care and MED/SURG background with the ability to assess and identify relevant acute and chronic medical conditions. CDI experience.

Employees are our number one asset.

UCHealth promotes a culture that invests in professional success and personal well-being through a comprehensive total rewards program. *

Recognition

• Performance bonus: UCHealth offers a 3-Year Incentive Bonus to recognize employee contributions to our success in quality, patient experience, organizational growth, financial goals and tenure. The bonus accumulates annually each October and is paid out in October during the third year of employment.

• Performance-based pay increase: The Annual Merit Pay Increase recognizes work performance that meets or consistently exceeds performance standards documented through UCHealth's established evaluation process and accounts for increased experience, skills and cost of living.

• Market reviews: All UCHealth positions are reviewed annually to ensure UCHealth base pay aligns with market standards. Base pay rates are adjusted as needed to stay market competitive.

Health and well-being

• Medical, dental and vision coverage.

• Access to 24/7 mental health and well-being support for employees and dependents.

• Discounted gym memberships and fitness resources.

• Free Care.com membership.

• Voluntary benefits such as accident insurance, critical illness insurance, group legal plan, identity theft protection, pet insurance, auto and home insurance, and employee discount programs.

• Time away from work: Paid time off (PTO), paid family and medical leave (inclusive of Colorado FAMLI), leaves of absence.

• Employer-provided basic life and accidental death and dismemberment coverage with buy-up coverage options.

• Employer-provided short-term disability and long-term disability with a buy-up coverage option.

Retirement and savings

• 403(b) plan with employer matching contribution.

• Additional 457(b) plan may be available.

• Flexible spending accounts for health care and dependent day care; health savings account available when enrolled in high-deductible (HD) medical plan.

Education and career growth

• UCHealth provides access to academic degrees and certificate programs to promote professional and personal growth.

• Up to 100% of tuition, books and fees paid for by UCHealth for specific educational degrees.

• Other programs may qualify for up to $10,000/year pre-paid by UCHealth or up to $5,250/year in the form of tuition reimbursement.

• Access to LinkedIn Learning, which offers thousands of virtual courses and seminars, and internal professional development opportunities.

• Employees have access to free assistance navigating the Public Service Loan Forgiveness program and submitting their federal student loans for forgiveness.

*Eligibility for some programs is based on an employee's scheduled work hours.

We improve lives. In big ways through learning, healing, and discovery. In small, personal ways through human connection. But in all ways, we improve lives.

UCHealth always welcomes talent. This position will be open for a minimum of three days and until a top applicant is identified.

UCHealth recognizes and appreciates the rich array of talents and perspectives that equal employment and diversity can offer our institution. As an equal opportunity employer, UCHealth is committed to making all employment decisions based on valid requirements. No applicant shall be discriminated against in any terms, conditions or privileges of employment or otherwise be discriminated against because of the individual's race, color, national origin, language, culture, ethnicity, age, religion, sex, disability, sexual orientation, gender, veteran status, socioeconomic status, or any other characteristic prohibited by federal, state, or local law. UCHealth does not discriminate against any qualified applicant with a disability as defined under the Americans with Disabilities Act and will make reasonable accommodations, when the do not impose an undue hardship on the organization.

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